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class=\u0022inside\u0022\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-publication-history\u0022 \u003E\n \n \u003Ch2 class=\u0022pane-title\u0022\u003EPublication history\u003C\/h2\u003E\n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022field field-name-field-highwire-publication-history field-type-text field-label-hidden\u0022\u003E\u003Cdiv class=\u0022field-items\u0022\u003E\u003Cdiv class=\u0022field-item even\u0022\u003E\u003Cul class=\u0022publication-history\u0022\u003E\u003Cli class=\u0022published\u0022\u003E\u003Cspan class=\u0022published-label\u0022\u003EFirst published\u003C\/span\u003E November 1, 1999.\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-pubdate bmjj-pub-date\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022field field-name-field-highwire-a-epubdate field-type-datetime field-label-inline clearfix\u0022\u003E\u003Cdiv class=\u0022field-label\u0022\u003EOnline issue publication\u0026nbsp;\u003C\/div\u003E\u003Cdiv class=\u0022field-items\u0022\u003E\u003Cdiv class=\u0022field-item even\u0022\u003E\u003Cspan class=\u0022date-display-single\u0022\u003ENovember 01, 1999\u003C\/span\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003C\/div\u003E\n\t\t\t\u003C\/div\u003E\n\t\t\u003C\/div\u003E\n\t\n\t\u003C\/div\u003E \u003C!-- \/.panel-row-wrapper --\u003E\t\n\t\n\t\u003C\/div\u003E\n\n \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-article-data-supp\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022item-list\u0022\u003E\u003Cul\u003E\u003Cli class=\u0022first last\u0022\u003E\u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022auto-clean\u0022\u003E\u003Cstrong\u003EAppendix\u003C\/strong\u003E\u003C\/div\u003E\u003Cp\u003EMEDICO-LEGAL IMPLICATIONS OF HEREDITARY NON-POLYPOSIS COLORECTAL CANCER\n \n \u003C\/p\u003E\u003Cp\u003EThe prodigious advancements in knowledge about genetic risk, natural\n history, recommended available surveillance and management, DNA testing,\n and the need for genetic counselling collectively are having a significant\n impact on the standard of care for hereditary non-polyposis colorectal\n cancer (HNPCC) and familial adenomatous polyposis (FAP), as well as for\n patients with a variety of other hereditary cancer prone disorders. For\n example, a standard of care has been adjudicated in favour of a patient\n with the hereditary breast-ovarian cancer syndrome who followed the recommendations\n of her gynaecological oncologist and a cancer geneticist to undergo prophylactic\n oophorectomy but whose insurance company failed to reimburse her for this\n procedure. While her petition for reimbursement was denied at the district\n court level, the Nebraska Supreme Court rendered a favourable decision\n on her part, commanding the insurance company (Blue Cross\/Blue Shield)\n to provide reimbursement for this indicated procedure.\u003Csup\u003E\u003Cspan style=\u0022font-size: 69.44%\u0022\u003E165\u003C\/span\u003E\u003C\/sup\u003E\u003Cbr\/\u003E\u00a0In a legal decision involving a Lynch syndrome II patient, the\n family of the plaintiff received an out of court settlement from the defendant\n HMO for its failure to diagnose colorectal cancer. This patient had a positive\n family history of multiple occurrences of early onset colorectal cancer\n in her first and second degree relatives which were consistent with Lynch\n syndrome II. The plaintiff, a 16 year old girl, presented to the defendant\n HMO with symptoms for about one year consisting of constipation, weight\n loss, fatigue, and occasional abdominal pain, all of which had become progressive.\n A computed tomography (CT) scan of the abdomen failed to show any abnormality.\n Nurse practitioners subsequently shared in the bulk of her care during\n the following three years. The patient\u0027s mother requested that her daughter\n undergo colonoscopy because of her strong family history of early onset\n colorectal cancer (CRC). However, a flexible sigmoidoscopy was ordered\n because the physicians associated \u0022hereditary\u0022 with FAP. The physician\n assistant who performed the flexible sigmoidoscopy reassured the mother\n that, owing to the relatively young age of her daughter, this procedure\n was sufficient, particularly since adenomas or other lesions were not observed\n in her at time of flexible sigmoidoscopy. However, the patient\u0027s weakness\n and weight loss persisted and at the age of 19 she presented with jaundice.\n A CT scan of the abdomen disclosed metastases to multiple sites in the\n liver and regional lymph nodes. At exploratory laparotomy, the diagnosis\n of moderately differentiated adenocarcinoma of the caecum was established,\n during which time biopsies of the liver disclosed metastatic adenocarcinoma\n consonant with CRC origin. The patient died at the age of 20.\n \u003Cbr\/\u003E\u00a0The expert witness (HTL) noted that the medical, pathology, and\n family history findings did not support a diagnosis of FAP as usually recognised,\u003Csup\u003E\u003Cspan style=\u0022font-size: 69.44%\u0022\u003E166\u003C\/span\u003E\u003C\/sup\u003E\n but nevertheless the attenuated form of FAP (AFAP)\u003Csup\u003E7\u003C\/sup\u003E\u003Csup\u003E\u003Cspan style=\u0022font-size: 69.44%\u0022\u003E167\u003C\/span\u003E\u003C\/sup\u003E\n was worthy of consideration. However, because of the proximal predominance\n of adenomas (in AFAP), colonoscopy is required.\u003Csup\u003E\u003Cspan style=\u0022font-size: 69.44%\u0022\u003E118168\n \u003C\/span\u003E\u003C\/sup\u003EAttention\n was called to the exclusion of atypical FAP in the patient, thereby necessitating\n colonoscopy as opposed to flexible sigmoidoscopy as the appropriate diagnostic\n procedure.\n \u003Cbr\/\u003E\u00a0Another litigation because of failure to meet the standard of\n care was brought against a physician in California.\u003Csup\u003E\u003Cspan style=\u0022font-size: 69.44%\u0022\u003E169\u003C\/span\u003E\u003C\/sup\u003E\n The plaintiff, during her initial pregnancy, related to her physician that\n her family had been involved in one of the original HNPCC studies. During\n a second pregnancy, she disclosed to the defendants that she was experiencing\n rectal bleeding and that she had a \u0022mass\u0022 protruding from her rectum during\n defaecation. However, neither a rectal examination nor a stool Guiac was\n performed and she was told that her problem was because of\u00a0 \u0022haemorrhoids\u0022.\n However, the plaintiff demanded attention for the haemorrhoids and bleeding,\n and when endoscopy was performed a CRC was identified with metastasis to\n lymph nodes and liver. Because of the failure to establish a diagnosis\n over a two year period, it was argued that this contributed to her advanced\n stage of disease and a decrease in survivability. The jury verdict was\n in favour of the plaintiff.\u003Csup\u003E169\u003C\/sup\u003E\u003Cbr\/\u003E\u00a0Finally, in a case involving FAP referred to as the Safer case,\u003Csup\u003E\u003Cspan style=\u0022font-size: 69.44%\u0022\u003E170\u003C\/span\u003E\u003C\/sup\u003E\n at the age of 35 the father of the litigant had been evaluated by the defendant\n surgical oncologist. A retroperitoneal cancer was operated on and the diagnosis\n of FAP was established. The surviving spouse claimed that, although the\n surgeon discussed her husband\u0027s diagnosis, treatment, and cancer management,\n he failed to disclose the genetic risk for FAP even though the hereditary\n nature of FAP was known fully at the time the surgeon was treating the\n husband and thereby prevailing medical standards of care required a warning\n of risk for FAP so that the patient\u0027s children, then aged 10 and 17, might\n benefit from early colon surveillance. Subsequently, one of the children,\n at the age of 36, experienced lower abdominal pain and underwent surgery\n and extensive chemotherapy for CRC in concert with FAP. She examined her\n father\u0027s medical records and concluded that her condition was the same,\n namely FAP. Further inquiry led her to the following conclusions: (1) her\n condition was hereditary; (2) her father\u0027s surgeon knew of the hereditary\n nature of her father\u0027s disease; (3) she should have been suspected of being\n at increased risk for FAP; (4) because of this risk, she should have been\n warned to monitor for such a disease; and (5) her cancer would probably\n have been preventable had surveillance been done. \u0022The daughter filed a\n claim of negligence against the estate of the surgeon, alleging the following:\n (1) that he had a duty to warn those known to be at risk of avoidable harm\n from a genetically transmissible condition existing in his patient, (2)\n that the physician\u0027s duty did extend to members of the immediate family\n of his patient, and (3) that he had breached these duties.\u0022\u003Csup\u003E171\u003C\/sup\u003E\n The suit was won by the plaintiff in 1996.\n \u003Cbr\/\u003E\u00a0\n \n \u003C\/p\u003E\u003Cp\u003E165 Lynch HT, Severin MJ, Mooney MJ, Lynch JF. Insurance adjudication\n favoring prophylactic surgery in hereditary breast-ovarian cancer syndrome.\n \u003Cem\u003EGynecol\n Oncol\u003C\/em\u003E 1995;\u003Cstrong\u003E57\u003C\/strong\u003E:23\ufffd6.\n \u003Cbr\/\u003E166 Lynch HT, Smyrk T, Lynch J. Genetics and cancer of the gastrointestinal\n tract. In: Wanebo HJ, ed. \u003Cem\u003ESurgery for gastrointestinal cancer: a multidisciplinary\n approach\u003C\/em\u003E. Philadelphia: Lippincott-Raven, 1997:59\ufffd86.\n \u003Cbr\/\u003E167 Dugaw JE, Lynch HT. Medical students as \u0022probation officers\u0022 for\n juvenile offenders. \u003Cem\u003ENebr State Med J\u003C\/em\u003E 1971;\u003Cstrong\u003E56\u003C\/strong\u003E:60\ufffd2.\n \u003Cbr\/\u003E168 Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening:\n clinical guidelines and rationale. \u003Cem\u003EGastroenterology\u003C\/em\u003E 1997;\u003Cstrong\u003E112\u003C\/strong\u003E:594\ufffd642.\n \u003Cbr\/\u003E169 Seamon v Miller, Sacramento County Sup Ct, Docket 534952 (1994).\n \u003Cbr\/\u003E170 Safer v Estate of Pack, 677 A.2d 1188 (1996).\n \u003Cbr\/\u003E171 Lynch HT, Paulson J, Severin M, Lynch J, Lynch P. Failure to diagnose\n hereditary colorectal cancer and its medicolegal implications: a hereditary\n nonpolyposis colorectal cancer case. \u003Cem\u003EDis Colon Rectum\u003C\/em\u003E 1999;\u003Cstrong\u003E42\u003C\/strong\u003E:31\ufffd5.\n \n \n \n \u003C\/p\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-custom pane-1\u0022 \u003E\n \n \u003Ch2 class=\u0022pane-title\u0022\u003ERequest permissions\u003C\/h2\u003E\n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cp\u003EIf you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center\u0026rsquo;s RightsLink service. 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